BRONCHIAL TUMOURSBRONCHIAL TUMOURS

Bronchial tumours , widely divided in to primary lung

tumours and secondary or metastatic cancer.

The majority of primary lung tumour is bronchial carcinoma,

and It is one of the most common cancer world – wide,

It causes 18% of all cancer death.

Cigarette smoking is by far the most important single factor

in the causation of the lung cancer. It is thought to be

directly responsible for at least 90% of lung carcinomas,

and the risk is directly proportional to the amount smoked

and to the tar content of the cigarettes.

Risk falls slowly after smoking cessation , but remain above

the risk of non- smokers.

• Bronchial CarcinomaIs the commonest cause of cancer death in men or women

in the UK. More women now die from lung cancer than

breast cancer in the UK and USA.

In practical term we can divide bronchial cancer in to two

groups.

1- Non- small cell lung cancers ( NSCLC), that accounts for

75%-80% of all lung cancers, these include ( squamous ,

adenocarcinoma and alveolar cell cancer)

2- Small cell lung cancer (SCLC), that account for 20% -

25%of all lung cancers.

Clinical featuresLung cancer presents in many different ways. Most

Commonly, symptoms reflect local involvement of the

bronchus, but may also arise from spread to the chest wall

or mediastinum ,from distant blood borne spread or, less

commonly , as a result of a variety of non-metastatic

paraneplastic syndrome.

A- Local tumour effect- Persistent cough , is often dry but it might associate with

purulent sputum if there is secondary infection or change in

usual cough.

- Haemoptysis, is a common symptoms especially in

tumour arising from central bronchi, occasionally large

tumours invade large blood vessels, that can cause

massive haemoptysis .- Chest pain , that could indicate chest wall involvement

with the tumour .- Unexplained SOB, due to narrowing of bronchial tree or

bronchial obstruction.- Hoarseness of voice, indicate involvement of Lt recurrent

laryngeal nerve.- Dysphagia , could be due to large tumour invading or

narrowing oesophagus.

- Shoulder pain due to apical tumours that invades

brachial plexus and cause wasting or weakness of small

muscles of the hands.

B- Metastatic tumour effects.

- Cervical /supraclavicular LN enlargement.

- Palpable live edge.- Bone pain or pathological fracture due to bone

metastasis- Neurological manifestation due to cerebral metastasis.- Hypercalcaemia due to bone metastasis ( the patient

may present with polyuria and poly dypsia with abdominal pain) .

C-Non –metastatic extra pulmonary manifestation of lung cancer.

1- Endocrine-Inappropriate ADH secretion that cause hyponatremia.- Ectopic ACTH( adrenocorticotrophic ) hormone secretion,that cause Cushing's syndrome. - Hypercalcaemia due to secretion of parathyroid hormone - Carcinoid syndrome.- Gynaecomastia 2- Neurological- Polyneuropathy- Myelopathy- Cerebellar degeneration- Myasthenia like syndrome( Lambert- Eaton Syndrome)

3- Others

- Clubbing of fingers- Hypertrophic pulmonary osteoarthropathy - Nephrotic syndrome - Polymyositis and dermatomyositis.

Physical signs

Examination is usually normal unless there is significant

bronchial obstruction, or the tumour has spread to pleura ,

mediastinum or supraclavicular LNs.

A tumour obstructing a large bronchus produce a physical

sign of collapse.

A monophonic or unilateral wheeze , suggests the

presence of fixed bronchial obstruction, and the presence

of strider indicates obstruction at or above the level of

Carina.

Phrenic nerve paralysis , cause unilateral diaphragmatic

paralysis , that will give dull percussion with absent

breath sound in lung base.

Involvement of the pleura may produce plural rub or

Effusion. Bronchial cancer is the common cause of

Superior vena cava syndrome, that initially presents as

bilateral jugular vein engorgement and later as oedema

affecting face , neck arm and conjunctivae

Horner syndrome;

It represents unilateral (meiosis, ptosis, enophthalmos and

Anhidrosis), this is due to direct involvement of the

sympathetic chain by the tumour.

Investigations:

The main aims of investigations are to confirm the

diagnosis , establish the histological cell type and define

the extend ( stage) of the disease.

1- Blood tests including sodium , calcium , liver function test

2- CXR, is important investigation , the common radiological

features of bronchial cancer are;

- Unilateral hilar enlargement- peripheral pulmonary opacity- Lung, lobe or segmental collapse- Plural effusion- Broadening of mediastinum- Enlarged cardiac shadow- Elevation of hemidiaphragm- Rib or bone distruction

3- CT chest (Staging CT), to determine the site and the

extend of the tumour, and some time helps to determine

the site for the biopsy through bronchoscopy.

4- Flexible Bronchoscope, around three quarters of primary

lung tumours can be visualised using a flexible

bronchscope. Bronchial biopsies and brush samples can

be taken for pathological examination, and a direct

assessment can be made of operability as judged by

proximity of central tumour to carina.

If the tumour is not visible at bronchoscopy, washing and

brushing can be taken from radiologically affected lung

Segments.

5-CT or USS guided biopsy, is important method for

diagnosis especially for peripheral lesions that is not

accessible through bronchscopy. This method carries a

small risk of Pneumothrax.

6- Sputum cytology, can be valuable diagnostic aid in

patients not fit for bronchoscopy.

7- Plural biopsy , is indicated when there is plural effusion.

8- Mediastinoscopy, especially in patients with mediastinal mass or Mediastinal LN enlargement.

9- some times thorachoscopy or thoracotomy are required to obtain diagnosis.

10- In patients with metastatic disease the diagnosis can often be confirmed by needle aspiration or biopsy of affected LNs, skin lesions, liver or bone marrow.

11- others like Bone scan, MRI or CT head

12- new investigation is PET scan ( Positron Emission Tomography ) .